摘要
目的:探讨DSA动态采集记录在喉癌术后吞咽功能评价中的应用。
方法:采用DSA设备动态采集记录喉癌术后患者吞咽复方泛影葡胺的过程,按不同手术分组测定各患者吞咽物咽传输时间。
结果:DSA采集静态图像可显示清楚的咽部解剖结构等,并能动态采集到喉癌术后患者误吸的过程。将患者分为喉裂开声带切除术后、喉水平部分切除术后、喉垂直部分切除术后、喉垂直水平部分切除术后、全喉切除发音重建术后各组,将其各段咽传输时间与正常对照组做比较结果显示:C2L值(舌骨首次向上运动至造影剂头部到第2颈椎体后下缘水平时间):喉垂直水平部分切除术组的与正常对照组比较p<0.05,差异有统计学意义;Em值(舌骨首次向上运动至会厌到达起始位置):喉垂直水平部分切除术后组、喉垂直部分切除术后组与正常对照组比较,p<0.05,差异有统计学意义;其余组间值比较结果为p>0.05,差异均无统计学意义。
结论:喉癌手术后的患者大多有不同程度的吞咽障碍,喉水平垂直部分切除术后患者可能较易发生咽传输时间的减慢。DSA动态采集记录的咽传输时间为喉癌术后吞咽功能评价提供一个新的客观指标。
Laryngocarcinoma accounting for carcinoma of the head and neck tumors of 13.9%, account for 2.1% of the systemic malignancy. Along with the development of laryngeal surgery, all kinds of partial and total laryngectomy gradually widely used in the treatment of laryngeal cancer, in principle is the premise of complete resection of the tumor as much as possible to retain or rebuild the function of larynx to improve quality of life. Laryngeal function including respiratory, pronunciation, swallowing .Scholars evaluated respiratory function through clinical signs, decannulation rate, oxygen saturation, and other indicators; evaluate pronunciation through audio collection, aerodynamics, vocal movement, EMG test parameters. At the same time, the evaluation of swallowing function in the clinical detection, although some progress has been made, but has yet to formulate a clear indicators to seek an objective standard is still the target of public criticism.
Due to local tumor invasion, oppression machinery, and other soft tissue formed flexibility to reduce consumption channel obstruction, but also because of nerves, causing muscle paralysis; can lead to severe dysphagia. Along with the development of laryngeal surgery, all kinds of partial resection of total laryngectomy gradually widely used in the treatment of laryngeal cancer, but in the resection of the lesion, but also to the relevant organs of the normal function of varying extent of the impact, and even serious aspiration or shortness of breath.Post-operative patients must rely on short-term survival of nasal feeding tube, after the nasal feeding tube removed dysphagia patients are still too many. Surgical muscle injury and the subsequent muscle fibrosis, and with input from nerve fibers and nerve receptors can be formed without feeling local area. These factors can lead to swallowing the gag reflex delay, pharynx feeling diminish or disappear, which is bound to lead to aspiration. People emphasis on how to preserve and rebuild the function of the larynx surgery .The function of one of the swallowing function assessment,testing has become a method of otolaryngology - head and neck surgeon concern. In recent years many clinical evaluation methods and swallowing function tests are used in the diagnosis and assessment of difficulties.The Japanese scholars to formulate an evaluation of the seven dysphagia, difficulty swallowing not only evaluate the extent of the clinical and rehabilitation. Furthermore, as computer imaging technology with the anatomy, physiology direction of infiltration, swallowing various functional assessment methods have emerged, such as videoendoscop ic swallowingstudy (VESS), Flexibl Endoscopic Evalation of Swallowing with Sensory Testin (FEESST), Radionuclide quantitative analysis, swallowing pressure measurement, inspection Although these features images from the visual manifestation of swallowing process, but still do not have a unified standard for judging. Yang Yan-min, who used DSA equipment and the normal flu patients with pharyngeal different firms swallowing function checks to collect on the base of the skull, cervical issued 7 lateral plane is dynamic image transmission time pharyngeal parallel to the determination of record Mission barium swallow from the start to open the entire esophagus dynamic process, embodied in the DSA equipment to the advantages of this field study. We are on digital subtraction angiography (DSA) in the larynx dynamic collection records after swallowing function evaluation of the application.
We used the DSA equipment to record the process of swallowing the compound diatrizoatc meglumine of 30 patients who has been explicitly routine pathologic diagnosis and underwent different surgical procedures. There are 6 patients who underwent laryngofission chordectomy, 2 patients post-supraglottic horizontal laryngectomy, 7 patients post-vertical hemilaryngectomy, 9 patients post-partial vertical horizontal laryngectomy, 6 patients post-total laryngectomy and voice reconstrction. From the static image, signs of cervical, pharyngeal anatomical structure can be clearly shown: oropharynx, laryngohypopharynx, the pharyngeal posterior wall, hyoid, the epiglottic vallecula and appendage of ventricle of larynx. The normal swallowing, aspiration in the process of swallowing disorder can be collected in dynamic images. DSA images showed the stagnation of contrast agent in vallecula and pyriform sinus of two patients, who drink water without symptomatic bucking consciously after laryngofission. It would potentially cause aspiration hazards. 24 cases with symptoms after vertical hemilaryngectomy or vertical-horizontal laryngectomy have different levels of aspiration. Image for performance show that the contrast agent inflow in vestibule of larynx or tracheal entrance, and even deeper.Reasons for the patients from bucking is incomplete closure of the epiglottis or glottic defective closure. One case of patients after total laryngectomy and voice reconstrction is recurrent carcinoma after partial laryngectomy, and the images showed obvious aspiration, which may be for postoperative myofibrosis and the damage importation of nerve fibers and nerve receptors. The gag reflex delay in swallowing is related to decrease or disappearance of pharyngeal feeling . In this study , images showed no significant swallowing process aspiration in group of patients after total laryngectomy, but more imaging performance for the pyriform sinus stagnation.Pharyngeal retention index increased potential risk of aspiration. According to the point of swallowing function and the order, that is,①the first time hyoid upward movement (H1) was established to the beginning.②head of contrast agent bolus to the decocted later second body of cervical vertebra level (C2L).③the bottom of the epiglottic vallecula (BV).④head of contrast agent bolus to the decocted later fourth body of cervical vertebra level (C4L).⑤epiglottis reach initial position (Em). We compared the group of patients with pharyngeal swallow transmission time period. The value of that C2L: vertical–horizontal laryngectomy group and the normal control group, p <0.05, there was significant differences in statistics. Value of Em: vertical–horizontal laryngectomy group , vertical hemilaryngectomy group and the normal control group, p <0.05, there were significant differences. Remaining group results are compared p> 0.05, there was no significant difference. The patients after vertical–horizontal laryngectomy may be more prone to the slow swallow transmission time. This shows that after partial laryngectomy patients with swallowing difficulties not only for the performance of aspiration, but also to swallow transmission time was significantly delayed than the normal control group. The other patients undergo surgery and the normal control group were not significantly different.
After partial laryngectomy have different levels of aspiration, and it closely related to surgical resection. Larger resection of larynx, more serious aspiration. It is reported that the aspiration of vertical horizontal (3 / 4) laryngectomy group is serious than vertical hemilaryngectomy. The extent of its aspiration to a lighter weight were: chordectomy, vertical-laryngectomy, the epiglottis reservations cricopharyngeus anastomosis, half the level of supraglottic laryngectomy, some of the vertical level (3 / 4 ) excision, do not retain epiglottis cricopharyngeus anastomosis. In our study most patients after laryngofission chordectomy with laryngeal carcinoma didn’t suffer from aspiration. We have adopted a style of Arsland total laryngectomy and thyroid cartilage valve restoration of the partial laryngectomy, and have gained good retention and restoration of laryngeal function effect. These patients with DSA images recorded didn’t show obvious aspiration.
On the basis of Japanese scholars before a developed dysphagia seven rating, we follow-up postoperative patients with laryngeal cancer 22 patients included in the above study and recorded swallowing function recovery. The remaining 8 patients dropped out . Can be seen from the results of follow-up, one case of total laryngectomy patients with the opportunity aspiration accout for the study of the 33.3% of patients. Feeding posture can be adjusted to prevent the occurrence of choking. And this is just the patient relapse in glottic cancer 3 months after partial laryngectomy. Follow-up of the two cases after the supraglottic horizontal laryngectomy was given the opportunity to aspiration.Three cases of aspiration followed 3 / 4 partial laryngectomy. The follow-up patients with vertical laryngectomy or laryngofission chordectomy have normal feeding. The majority of patients after partial laryngectomy began to eat in 10-14 days by scientific guidance and training. And patients with mild aspiration are asked to take a certain position consumption. We ask the patients with refractory bucking to wear airbag casings,and inflatable casing before eating. We will continue our clinical strategy, to achieve satisfactory results to prevent aspiration.
In conclusion, DSA dynamic collection we used can be comprehensively and objectively record the entire process of swallowing, calculate pharyngeal phase transmission time. Qualitative and quantitative analysis provide a new subjective basis ,which can evaluate the swallowing function of patients with laryngeal cancer after partial laryngectomy ,then aspiration will be reduced.
引文
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